Studies have shown that patients with chronic conditions such as heart failure adhere to only 50% to 60% of medications as prescribed,1,2 despite evidence that medical therapy prevents death and improves quality of life. Improving medication management and adherence is dependent on redesigning the traditional educational approach.
Current medication education focuses on unidirectional information delivery—telling patients what to do in a written format. An ongoing, bidirectional exchange of information between patients and providers is more consistent with adult learning theory,3,4 and person-centered principles of shared decision making,5,6 and may be more effective. Active listening, planning, and documentation of patients’ medication goals regarding why, what, how, and when to take prescribed medications and providing feedback on patient performance and progress toward established goals may also improve medication management.3,5 Technology-based approaches for facilitating medication management are available7; however, current designs are predominantly reminder systems or 1-way communications that lack a skill-based approach, a patient goal, and a feedback mechanism.8,9 Without assessment of learning or consistent documentation via a common portal or electronic health record (EHR) link, lack of connectivity across settings poses a barrier to long-term medication management.
The purpose of the “Digital Drag and Drop Pillbox” (D-3 Pillbox) innovation project was to design and develop a pedagogically appropriate instrument for use across clinical settings. The specific aims of this study were to (1) obtain patient input into the design of the new skill-based educational model for teaching medication management, (2) assess the feasibility of using an electronic tablet (e-tablet) as a mode of delivery for skill-based education in the inpatient and ambulatory clinical settings, and (3) evaluate the performance of the e-tablet for assessing a core set of medication management skills (baseline aptitude [health literacy score], accuracy [medication reconciliation], competence [performance score], and knowledge [learning check score]).
Patient Input in the Digital Drag and Drop Pillbox Design
Patients were involved in designing the Digital Drag and Drop Pillbox in 3 phases. First, patients participated in small group sessions in which the teach-back method was used for medication education using an actual pillbox. Next, feedback was obtained from patients regarding how the content would be perceived and used if it were available in an e-tablet format. Finally, patients used and evaluated the digital application of the pillbox on e-tablets using a Web-based application platform. Actual pill images were integrated in the program in a pick list so that patients could identify the correct pill and dose and then “drag and drop” the pill image into the correct time and frequency. Using the focus group feedback, the educational content about each pill was combined in this skill-based exercise. “Challenge questions” were added at the conclusion of the exercise to assess learning about the medications themselves and the appropriate management of the medications.
The approach to soliciting and integrating the patient perspective in the exercise was planned using applied principles of simulation and adult learning theory (Figure). We incorporated the 6 categories most applicable for medication education: (1) the content of written materials to be at fifth grade level or lower; (2) inclusion of patient-oriented outcome measures; (3) inclusion of pictures and drawings; (4) use of patients' native language, in particular, the recommendation for use of first language; (5) use of comprehension-enhancing instruments, such as participatory, manipulative exercises; and (6) patient participation in the development process.11
Feasibility Pilot Study
A feasibility pilot study was conducted to evaluate the new educational model and describe the patients’ response to the change from text-based information delivery to interactive skill-based learning using the patients’ own medications. We evaluated a cohort of 25 patients admitted to a university-based hospital with acute decompensated heart failure. The institutional review board approved the protocol, and all participants provided written informed consent.
Patient-reported outcome (PRO) surveys were used to determine baseline health literacy (Rapid Evaluation of Adult Literacy in Medicine)12 and medication adherence (Morisky Medication Adherence Scale) (Table 1).13 Patients' knowledge (understanding of the content) (Table 2), perceived feasibility and usability of the e-tablet (Table 3), and satisfaction with the application (Table 3) were evaluated using 2 medication-related items from the Hospitalized Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Skill performance (% accuracy) and skill completion (% competency) were scored as 3-level categories.
Patient demographics, feasibility, usability, and performance were analyzed for the single group using descriptive statistics. A Kruskal-Wallis test was used to determine the difference in performance by 3 levels of health literacy.
All nurses on the heart failure progressive care unit and selected nurses in the outpatient cardiology clinic were trained to use the Digital Drag and Drop Pillbox according to the standardized protocol in Table 4. Nurses invited each patient to participate in education about their medications using the e-tablets. After obtaining informed consent, nurses logged into the e-tablets to obtain access to patients’ protected health information, including prescribed medications. Patients registered and logged into the e-tablet to ensure a secure environment for protected health information. The nurse completed medication reconciliation by verifying the patients’ active medication list in the EHR with the list appearing in the e-tablet D-3 Pillbox application. Next, the nurse correctly “filled” the pillbox by “dragging and dropping” tablet images for the correct drug, dose, and dosing frequency and clicked “set.” Then, the correct pill and dosing regimen on the e-tablet was “cleared,” removing medication images from view, and the e-tablet was given to the patient. The patient then completed PRO surveys, the pill management “drag and drop” exercise, and the feasibility and usability questions.
Patients practiced the exercise as many times as they liked during the hospital stay. Before patient discharge, a copy of the D-3 Pillbox summary report was printed for the patient and included in the patient’s medical record for postdischarge follow-up. Nurses in the clinic were also trained on the D-3 Pillbox application and repeated the exercise with patients at the follow-up visit.15
Among the patients who agreed to participate (n = 25), one had incomplete data and could not be used for analysis. The mean age was 59 (range, 39–89) years, 50% of the participants were men, 62% were black, and 54% were insured by Medicare or Medicaid. All patients had 3 or more chronic conditions, requiring 8 or more medications, on average. In addition, 46% had attained a seventh-grade education or lower, and 31% scored “very low literacy” on the Rapid Evaluation of Adult Literacy in Medicine health literacy questionnaire (Table 5). Most patients were able to complete the e-tablet–based educational program in the course of 1 hour, with a completion rate varying at baseline across all levels of health literacy. However, by discharge, 98% of all patients accurately completed the medication management skills, regardless of health literacy level.
Patient scores on learning outcomes, accuracy (medication list verification), competence (skill completion/performance), and knowledge (learning checks) are shown in Table 5. Adherence scores were relatively evenly split into high (31%), medium (38%), and low (31%). Few patients correctly answered 4 of 4 posttest medication questions correctly on the first try (25%). When baseline accuracy was evaluated according to the level of health literacy, patients with higher levels of health literacy performed better (Kruskal-Wallis χ2(2) = 10.968, P = .004).
Patient-reported feasibility and usability were acceptable across all domains (Table 3). Medication goals and patient engagement were captured on a final report that was provided to patients and providers to give feedback on strengths and gaps in learning in the postdischarge follow-up phone call and clinic visit. Change over time in learning outcome was not assessed; however, nurses observed a trend of improved accuracy with practice.
Our findings suggest that a skill-based approach using an e-tablet and the patient's own medication list is a feasible solution for teaching medication self-management for patients with chronic illness. This approach has 2 unique capabilities. First, it overcomes health literacy barriers through the use of pill images; second, it assesses and evaluates learning outcomes longitudinally. These advantages surpass traditional text-based print materials that do not easily accommodate frequent regimen changes and do not present patients with individualized feedback on learning and improved skill performance over time.
In this study, the population was characterized by the complexity of the typical medication regimen. The pedagogical basis for integrating skill development is to address the fundamental need for patients themselves to recognize, understand, and account for the dynamic nature of a medication regimen. Particularly in the case of chronic illness with multiple comorbidities in which changes in both symptom experience and medications are often poorly communicated between patients and providers, the patient's ability to self-manage and self-advocate is critically important.5,16
The Digital Drag and Drop Pillbox uses skill-based learning to advance medication education by not only addressing what to take but also eliciting the patients’ input and participation in why, how, and when to take a medication. In addition, the instrument promotes active listening to patient preferences and negotiating for safe and acceptable instances when not to take it.17 As symptoms, concomitant illnesses, or severity of illnesses change, the regimen must also change. Patients inevitably face frequent changes between generic and brand medications from potentially multiple prescribing providers and many pharmaceutical sources. It is imperative that they obtain the skills necessary to manage changes in their medication regimen.
Evaluating these skills before discharge allows the care team to evaluate the patient's aptitude and ability to organize and take medications accurately. Perhaps more important, the timing of the assessment also stimulates discussion about medication-specific barriers, cost considerations, intolerance or adverse effects, and scheduling conflicts encountered as part of fitting medications into everyday life. As reported in similar studies,18 in 30% of cases in this pilot cohort, health literacy was lower than a third grade level, and at the time of discharge, information about medications was not learned.19 In our baseline needs assessments of patient experience, care team workflow, and the medication education processes, the prevalence of health illiteracy and low rates of actual learning achieved by the time of discharge were undiscoverable data. The data were not captured in the EHR. In preliminary work with patients to develop the intervention, patients reported that conversations with providers about learning achievement or confidence to self-manage the regimen were not taking place.
Electronic Health Record Integration
Although teach-back is a common approach used with both patients and healthcare providers for teaching medication management skills,20–22 the Digital Drag and Drop Pillbox is unique in that it integrates with the EHR. Integration enables data capture on the ultimate health education “trifecta”: (1) healthcare system support, measured by educational processes (content delivery, timeliness, responsiveness); (2) PROs (knowledge and skill acquisition, behavioral outcomes such as self-reported adherence, and learning satisfaction outcomes such as “understanding of medication information at discharge” and “satisfaction with the information received”); and (3) clinical outcomes (medication adherence surrogates such as blood pressure, lipid levels, or hemoglobin A1c). Generalizability of the findings is limited by the small number of patients with heart failure who participated in this feasibility pilot study and the specific configuration of the EHR used.
Patient Input Into Design
Patient input into the design of technology to support health and healthcare is increasingly important. Adoption is dependent on the acceptability of the user interface, and we recognize the value and weight of the patient perspective. Evidence for patient-oriented outcome measures in educational initiatives was notably missing in the review conducted by Bunge and colleagues,11 and methods and educational approaches designed by patients remain sparse. In designing the Digital Drag and Drop Pillbox, we solicited input from patients using in-depth interviews, observed e-tablet use patterns, and transcribed field notes of patient narrative on how technology could best meet their learning needs.
The Digital Drag and Drop Pillbox model was designed with the help of patients to improve the skills required to manage medications and to improve patient-provider communication around medication changes. By using a Web-based platform, the Digital Drag and Drop Pillbox model makes the “practice setting” accessible to patients and providers at any time, from hospital to clinic to home. Finally, the Digital Drag and Drop Pillbox successfully implements a pedagogically appropriate feedback loop, using baseline aptitude, patient-specific medications, and real-time feedback on skill competency reports for both patients and providers.
What’s New and Important
- Traditional medication education fails to assess aptitude or evaluate learning.
- Skill-based methods improve patient-provider engagement and learning outcomes.
- The “Digital Drag and Drop” Pillbox is a skill-based solution for the assessment and evaluation of learning outcomes, and electronic health record integration facilitates longitudinal evaluation of learning outcomes.
1. Wakefield BJ, Boren SA, Groves PS, Conn VS. Heart failure care management programs: a review of study interventions and meta-analysis of outcomes. J Cardiovasc Nurs
2. Oosterom-Calo R, van Ballegooijen AJ, Terwee CB, et al. Determinants of adherence to heart failure medication: a systematic literature review. Heart Fail Rev
3. Knowles MS. What is androgogy? In: Knowles MS, ed. The Modern Practice of Adult Education: From Pedagogy to Andragogy
. Engelwood Cliffs, NJ: Prentice Hall Regents-Cambridge; 2000:40–59.
4. Strauss AL, Sipe JC, Knowles JH. Health: whose responsibility? Science
5. Kleinman AEL, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Focus
6. Kleinman A. On illness meanings and clinical interpretation: not “rational man,” but a rational approach to man the sufferer/man the healer. Cult Med Psychiatry
7. Bosworth HB, Zullig LL, Mendys P, et al. Health information technology: meaningful use and next steps to improving electronic facilitation of medication adherence. JMIR Med Inform
8. García-Lizana F, Sarría-Santamera A. New technologies for chronic disease management and control: a systematic review. J Telemed Telecare
9. Granger BB, Bosworth HB. Medication adherence: emerging use of technology. Curr Opin Cardiol
10. Vrijens B, De Geest S, Hughes DA, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol
11. Bunge M, Muhlhauser I, Steckelberg A. What constitutes evidence-based patient information? Overview of discussed criteria. Patient Educ Couns
12. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med
13. Morisky DE, Ang A, Krousel-Wood M, Ward H. Predictive validity of a medication adherence measure for hypertension control. J Clin Hypertens
14. Arozullah AM, Yarnold PR, Bennett CL. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care
15. Sawyer T, Nelson MJ, McKee V, et al. Implementing electronic tablet-based education of acute care patients. Crit Care Nurse
16. Stewart S, Riegel B, Thompson DR. Addressing the conundrum of multimorbidity in heart failure: do we need a more strategic approach to improve health outcomes? Eur J Cardiovasc Nurs
17. Sandman L, Granger BB, Ekman I, Munthe C. Adherence, shared decision-making and patient autonomy. Med Health Care Philos
18. Westlake C, Sethares K, Davidson P. How can health literacy influence outcomes in heart failure patients? Mechanisms and interventions. Curr Heart Fail Rep
19. Bailey SC, Oramasionwu CU, Wolf MS. Rethinking adherence: a health literacy-informed model of medication self-management. J Health Commun
. 2013;18(suppl 1):20–30.
20. Hyrkas K, Wiggins M. A comparison of usual care, a patient-centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting. J Nurs Manag
21. Fidyk L, Ventura K, Green K. Teaching nurses how to teach: strategies to enhance the quality of patient education. J Nurses Prof Dev
22. O’Connor DM, Savageau JA, Centerbar DB, Wamback KN, Ingle JS, Lomerson NJ. Lesson in a pill box: teaching about the challenges of medication adherence. Fam Med